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Pandu Chikitsa (view source)

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|titlemode=append

|keywords=Pandu roga, kamala, koshthashakhashrita kamala, shakhashrita kamala, panaka, kumbhakamala, haleemaka, anemia, jaundice

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|description=Chikitsa Sthana Chapter 16. Management of Pandu (Anemia and ~~Disorders of Blood Deficiency~~)

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|description=Chikitsa Sthana Chapter 16. Management of Pandu (Anemia and diseases due to blood deficiency)

}}

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<big>'''[[Chikitsa Sthana]] Chapter 16. Management of Pandu (Anemia and ~~Disorders of Blood Deficiency~~)</big>'''

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<big>'''[[Chikitsa Sthana]] Chapter 16. Management of Pandu (Anemia and diseases due to blood deficiency)</big>'''

<big>'''Abstract </big>'''

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''Kamala'' is of two types in repect to location, ''shakhshrita kamala'' located in body tissues in the form of obstructed ''pitta'' and ''koshthashrita kamala'', localized to gut and can be easily removed by purgation while ''shakhashrita kamala'' needs to be brought to gut for removal.

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===Sanskrit Text, Transliteration and English Translation===

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== Sanskrit Text, Transliteration and English Translation ==

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</div></div>

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Now, we shall ~~explain~~ the chapter ~~on the treatment~~ of ~~''pandu roga'' ,~~ said Lord Atreya [1-2]

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Now we shall expound the chapter "Pandu Chikitsa" (Management of Anemia and diseases due to blood deficiency). Thus said Lord Atreya. [1-2]

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==== Five types of ''pandu'' ====

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=== Five types of ''pandu'' ===

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''Pandu roga'' is classified into five types as ''vatika, paittika, kaphaja, tridoshaja'' and ''mrittika bhakshhana janya pandu'' [3]

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==== Pathogenesis of ''pandu'' ====

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=== Pathogenesis of ''pandu'' ===

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Aggravated ''pitta'' predominant ''dosha'' vitiates the ''dhatu''. This vitiation of ''dhatus'' cause sluggishnesss (''shithilata'') and heaviness (''gaurava'') in the ''dhatu'' resulting in diminution of complexion (''varna''), strength (''bala''), unctuousness (''sneha'') and the qualities of ''ojas''. Thus, the person develops diminished blood (''rakta'') and the fatty tissue (''medas'') and absence of the vitality of all the tissues (''nihsara'') decreases functional status of sense organs (''sithilendriyah'') and discoloration of the body. ''Hetu'' (etiological factors and pathogenesis) and the sign and symptoms of the disease will be explained hereafter [4-6]

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==== General etio-pathogenesis of ''pandu'' ====

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=== General etio-pathogenesis of ''pandu'' ===

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Indulgence in the above factors aggravates ''pitta'' seated in the cardiac region and then this ''pitta'' is forcefully propelled by the ''vata'' into the ten ''dhamanis'' (attached to the heart) and further into the whole body. There, it gets located in between the ''tvacha'' (skin) and the ''mamsa'' (flesh) and additionally vitiates the ''kapha, vata, rakta, tvacha'' and ''mamsa'' resulting in the development of various discolorations in the body like ''pandu'' (pale), ''haridra'' (yellow),and ''harita'' (green). This is called as ''pandu roga'' [7-11½]

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==== Premonitory symptoms ====

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=== Premonitory symptoms ===

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The premonitory symptoms of the disease are palpitations, ununctuousness, absence of sweating and fatigue [12]

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==== General symptoms of ''pandu'' ====

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=== General symptoms of ''pandu'' ===

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The signs and symptoms specific to each variety of ''pandu'' will be described henceforth.

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==== ''Vatika pandu'' ====

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=== ''Vatika pandu'' ===

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Indulging in ''vata'' increasing diet and regimens aggravates ''vata'' leading to ''vatika pandu roga''. The skin of the patient becomes blackish dawn colored and ununctuous. Its other symptoms are malaise, ache, pricking pain, tremor, pain in both the sides of the chest, headache; dried feces, distaste in the mouth; swelling, gaseous distention of the abdomen and weakness [17-18]

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==== ''Paittika pandu'' ====

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=== ''Paittika pandu'' ===

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''Pitta'' gets aggravated by indulging in ''pitta'' vitiating ''nidanas'' (diet and regimens) which by involving the blood etc. causes ''pittaja pandu''. Its symptoms are, change in complexion to yellowish/greenish, fever, burning sensation; morbid thirst and fainting; excessive perspiration and longing for cold things and environment. The person does not relish food, develops pungent taste, disfavors hot and sour things; gets sour eructations associated with burning sensation due to impaired digestion of food; emits foul smell from mouth; the urine and stool become yellow in color, has loose motions and develops weakness and fainting [19-22]

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==== ''Kaphaja pandu'' ====

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=== ''Kaphaja pandu'' ===

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Aggravated ''kapha'' by indulging in ''kapha'' increasing diet and regimen gives rise to ''kaphaja pandu roga'' through the pathogenesis described earlier. The sign and symptom of ''kaphaja pandu'' are heaviness, drowsiness, vomiting, whitish complexion, salivation, horripilation, prostration, fainting, giddiness, mental fatigue, dyspnea, cough, laziness, anorexia, obstruction in speech and voice, whitish coloration of the eyes, urine and feces; longing for pungent, ununctuous and hot things; and develops edema and sweet taste in the mouth [23-25]

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==== ''Tridoshaja pandu'' ====

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=== ''Tridoshaja pandu'' ===

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Indulging in the etiological factors of all the three types of ''pandu'' leads to aggravation of the three ''dosha'' resulting in ''tridoshaja pandu'' with the features of all the three types of ''pandu roga''. This type of ''pandu'' causes much distress to the patient [26]

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==== ''Mrittika bhakshana pandu'' ====

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=== ''Mrittika bhakshana pandu'' ===

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Person indulging in the habitual consumption of clay (''mrittika'') gets dośhā aggravated according to the taste of mud viz. astringent mud aggravates ''vata'', saline and alkaline mud aggravates ''pitta'' and sweet mud aggravates ''kapha dosha''. The clay further because of its ununctuousness causes dryness in the ''rasa'' (nutrients of the digested food). The clay due to its undigestable nature fills and blocks the channels of circulation leading to decrease in the sharpness of the senses, luster, energy and ''ojas'' (vital essence of the tissues). This quickly manifesting ''pandu'' results in the loss of strength, complexion and digestive power. Its clinical features are edema of the cheeks, peri orbital edema and edema on the eyebrows area, feet, umbilical region and the pudendum; infestation of worms in the ''koshtha'' (gastrointestinal tract) and loose motions, the stool associated with blood and mucus [27-30]

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==== Prognosis of ''pandu'' ====

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=== Prognosis of ''pandu'' ===

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Thus, the signs and symptoms of all the five type of ''pandu roga'' have been described [31-33]

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==== ''Koshthashakhashraya kamala'' ====

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=== ''Koshthashakhashraya kamala'' ===

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If a patient of ''pandu roga'' excessively follows pitta vitiating diet and regimen, the ''pitta'' so aggravated by involving the ''rakta'' and the ''mamsa'' causes ''kamala''. Its clinical features are the eyes, skin, nails and face of the patient become exceedingly yellow; stool and urine become reddish-yellow in color; complexion develops a color similar to that of a frog (found in rainy season); the senses get impaired; has burning sensation, indigestion, weakness, prostration and anorexia. This ''kamala'' is caused by excess of ''pitta'' is known as ''koshthashakhashrita'' [34-36]

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==== ''Kumbha kamala'' ====

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=== ''Kumbha kamala'' ===

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With the due course of time the disease (''kamala'') becomes deep seated (''kharibhuta'') resulting in excessive dryness of the body or afflicted tissue and thus becomes difficult to cure. This condition is called ''kumbha kamala'' [36½]

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==== Bad prognostic symptoms of ''kamala'' ====

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=== Bad prognostic symptoms of ''kamala'' ===

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If the stool and urine of the patient (of ''kamala'') become black and yellow; develops excessive edema; eyes and face becomes red colored; vomit, stool and urine are mixed with blood; the patient feels like going in darkness; has burning sensation, anorexia, morbid thirst, constipation, drowsiness and fainting; and the person looses his ''agni'' and consciousness; such patient may succumb to death quickly [37-38½]

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==== Principles of treatment ====

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=== Principles of treatment ===

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On the basis of the aggravated ''doshas'' specific medicines are to be administered to the patients of these two categories (which will be described later in the chapter). For the oleation of the patient of ''pandu'' and ''kamala panchagavya ghrita, mahatikta ghrita'' and ''kalyanaka ghrita'' should be given [39-43]

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==== ''Dadimadya ghritam'' ====

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=== ''Dadimadya ghritam'' ===

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Thus, ends the description of ''dadimadyaghrita'' [44-46]

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==== ''Katukadyam ghritam'' ====

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=== ''Katukadyam ghritam'' ===

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One ''pala'' each of ''katukarohini, musta, haridra, daruharidra, vatsaka'' in paste form, one ''karsha'' of each of ''patola, chandana, murva, trayamana, duralabha, krishna, parpataka, nimba, bhūnimba, devadaru'' should be added to one ''prastha'' of ''ghrita'' and four ''prasthas'' of milk. This medicated ghee cures ''raktapitta, jwara, daha, svayathu, bhagandara, arsha, asrigadara'' and ''visphotaka''. Thus described ''katukadya ghritam'' [47-49]

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==== ''Pathya ghritam'' ====

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=== ''Pathya ghritam'' ===

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The decoction of one hundred fruits of ''haritaki'' and the paste of fifty stalks of ''haritaki'' fruits should be added to one ''prastha'' of ghee and cooked. This medicated ghee cures ''pandu'' and ''gulma'' [50]

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==== ''Danti ghritam'' ====

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=== ''Danti ghritam'' ===

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One ''prastha'' of ghee should be cooked by adding (one ''prastha'' of) the decoction of four ''palas'' of ''danti'' and the paste of the green fruits of ''danti''. Intake of this medicated ghee cures ''pleeha'' (splenic disorders), ''pandu'' and edema [51]

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==== ''Drakshaghritam'' ====

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=== ''Drakshaghritam'' ===

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One ''prastha'' of old ghee should be added to half a ''prastha'' of ''draksha'' and cooked. This medicated ghee cures ''kamala, gulma, pandu, jwara, meha'' (polyuria) and ''udara roga'' (generalized abdominal enlargement)[52]

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==== ''Haridradi ghritam'' ====

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=== ''Haridradi ghritam'' ===

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''Ghrita'' prepared with ''haridra, triphala, nimba, balā, madhuka'' and buffalo’s milk and ghee is an excellent cure for ''kamala'' [53]

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==== ''Darvyadi ghritam'' ====

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=== ''Darvyadi ghritam'' ===

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One ''prastha'' of buffalo’s ghee prepared by adding with the decoction of five ''palas'' of ''darvi'' and the paste of ''kaleeyaka'' as per ''sneha kalpana'' cures ''kamala'' [54-55]

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==== Preparations for ''pandu roga'' ====

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=== Preparations for ''pandu roga'' ===

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*Physicians should give ''lauha bhasma'' impregnated for seven nights with cow’s urine along with milk for the alleviation of ''pandu roga'' [55-69]

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==== ''Navayasa churnam'' ====

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=== ''Navayasa churnam'' ===

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Take ''sunthi, pippali, maricha, haritaki, bibhitaki, amalaki, musta, vidanga'' and ''chitraka'' in one part each and nine parts of ''lauha bhasma'' and mix together. Intake of this recipe along with honey and ghee cures anemia, heart diseases, ''kushtha'' (group of skin diseases), ''arsha'' (hemorrhoids) and ''kamala''. This medicine propounded by ''krishnatreya'' is called ''navayasa churna'' [70-71]

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==== ''Mandura vataka'' ====

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=== ''Mandura vataka'' ===

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Thus ends the description of two types of ''mandura vataka''.[72-77]

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==== ''Tapayadi lauha'' ====

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=== ''Tapayadi lauha'' ===

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''Tapyadi yoga'' – ''Tapya, shilajatu,'' silver, ''mandura'' in the amount of five ''pala'' each should be added to one ''pala'' each of ''chitraka, haritaki, bibhitaka, amalaki, sunthi, pippali, maricha'' and ''vidanga''; and eight ''pala'' of sugar. This recipe should be taken by the patient habitually (by a ''pandu rogi'') in the dose of one ''karsha'' along with adequate amount of honey. After the digestion of this drug the patient should take wholesome food in small quantity and should avoid using ''kulattha, kakamachi'' etc. and pigeon meat [78-80]

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==== ''Yogaraja'' ====

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=== ''Yogaraja'' ===

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Thus ends the description of ''yogaraja'' [80-86]

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==== Preparations for ''pandu'' ====

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=== Preparations for ''pandu'' ===

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Two other recipes – Patients suffering from ''kamala'' should take the powder of one part each of ''lauha bhasma, haritaki'' and ''haridra'' along with honey and ghee and may also take the linctus of the powder of ''abhaya'' prepared by mixing with jaggery and honey [87-99]

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==== ''Dhatryavaleha'' ====

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=== ''Dhatryavaleha'' ===

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''Dhatryavaleha'' – ''Vanshalochana, sunthi, maduyashti'' powders, each in two ''pala''; one ''prastha'' each of ''pippali'' and ''draksha''; and half a ''tula'' of sugar crystal added with one ''drona'' of ''amalaki'' fruit juice and cooked till it changes into linctus form. One ''prastha'' of honey is added to it after it cools down. Intake of one ''panitala'' of this linctus cures ''kamala, pitta vikaras, pandu, kasa'' and ''haleemaka'' [100-101]

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==== ''Mandura vatakah'' ====

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=== ''Mandura vatakah'' ===

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''Mandura Vataka''-II: ''Shunthi, pippali, maricha, haritaki, bibhitaka, amalaki, chavya, chitraka, devadaru, vidanga, musta'' and ''vatsaka'' in one part each, made in the form of powder and added to equal quantity (12 parts) of ''mandura bhasma'', should then be boiled by adding eight times of cow’s urine over mild fire. After the recipe cools pills of one ''aksha'' each should be prepared and taken according to the power of digestion. This cures ''pleeha, pandu, grahani,'' and ''arsha''. The patient should take buttermilk and ''vatya'' (a roasted barley preperation) while taking this pill [102-104]

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==== ''Gaudo arishta'' ====

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=== ''Gaudo arishta'' ===

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''Manjishtha, rajani, draksha, bala moola'' (roots), ''lauha bhasma'', and ''lodhra'' should be added to jaggery and processed according to the method prescribed for ''arishta''. It is called ''gaudo-arishta'' and is useful for the patients suffering from ''pandu roga'' [105]

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==== ''Beejakarishta'' ====

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=== ''Beejakarishta'' ===

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Thus, ends the description of ''beejaka arishta'' [106-110]

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==== ''Dhatryarishta'' ====

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=== ''Dhatryarishta'' ===

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''Dhatryarishta'' - Two thousand fruits of ''amalaki'' should be crushed and the juice extracted should be mixed with one eighth the quantity of honey, half ''kudava'' of ''pippali'' and half ''tula'' of sugar. It should then be kept in an earthern jar smeared with ghee for one fortnight. It should be taken in appropriate dose in the morning and the patient should take wholesome food in small quantity after the digestion of the drug. This ''arishta'' cures ''kamala, pandu, hridroga, vatarakta, vishama jwara, kasa, hikka, aruchi'' and ''svasa''. Thus, ends the description of ''dhatrya arishta'' [111-113]

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==== Medicated water ====

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=== Medicated water ===

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Water boiled with the drugs belonging to ''sthiradi'' group is useful for drinking and the preparation of foods for ''pandu rogi''; while the patient of ''kamala'' should use the juice of ''draksha'' and ''amalaki rasa'' [114-115]

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==== Principles of treatment according to ''dosha'' ====

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=== Principles of treatment according to ''dosha'' ===

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The therapy should be dominated by unctuous drugs (oil, ghee etc) for ''vatika'' type of ''pandu''; by bitter and cooling drugs for ''paittika'' type and by pungent, bitter and hot drugs for ''kaphaja'' type of ''pandu'' [115-117]

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==== Treatment of ''mrittika bhakshanajanya pandu'' ====

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=== Treatment of ''mrittika bhakshanajanya pandu'' ===

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Different types of treatment should be given to the patient suffering from ''mrittika bhakshana janya pandu'', according to the different types of ''dosha'' aggravated. However, due to the specific type of etiological factor involved (clay eating), this type of ''pandu'' needs special type of treatment [123-124]

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==== ''Shakhashrita kamala'' (''kamala'' in body tissue with obstructive pathology) ====

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=== ''Shakhashrita kamala'' (''kamala'' in body tissue with obstructive pathology) ===

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The eyes, skin and urine of the patient become yellow while his stools become white in color. Additionally, the patients suffer from ''atopa'' (tympanitis), ''vishtambha'' (constipation associated with flatulence),and heaviness in the cardiac region, due to the displacement of ''pitta'' in the peripheral tissues (''shakha''), there is diminution in the flow of ''pitta'' (to the gastrointestinal tract) resulting in the gradual development of weakness, ''agnimandya'' (low digestion), ''parshva'' (pain in the sides of chest), ''hikka'' (hiccups), ''shvasa'' (dyspnea), ''aruchi'' (anorexia) and ''jwara'' [124-128]

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==== Treatment of ''shakhashriat kamala'' ====

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=== Treatment of ''shakhashriat kamala'' ===

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''Katu'' (pungent), ''teekshna'' (sharp), ''ushna'' (hot), ''lavana'' (saline) and extremely ''amla'' (sour) drugs should be continued till the stool of the patient acquires the color of ''pitta'' and the ''vata'' gets alleviated. When the ''pitta'' returns to its own habitat, the stool gets colored with ''pitta'' and the patient is relieved of complications, then further, the line of treatment described earlier for the treatment of ''kamala'' (''koshthashrita'') should be used [130-132]

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==== ''Haleemaka'' (obstructive jaundice) ====

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=== ''Haleemaka'' (obstructive jaundice) ===

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If a patient suffering from ''pandu'' develops green, black or yellow color and suffers from diminution of strength and enthusiasm; drowsiness, ''agnimandya'' (low digestion), mild fever, lack of libido (''strisu aharsho''), ''angamarda'' (malaise/ body ache), dyspnea, ''trishna'' (morbid thirst), anorexia and giddiness, the ailment is called ''haleemaka'' and is caused by the aggravation of ''vata'' and ''pitta dosha'' [132-134]

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==== Treatment of ''haleemaka'' ====

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=== Treatment of ''haleemaka'' ===

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The patient should take ''drakshaleha'' described earlier (vide verse 100-102 in this chapter in the name of ''dhatryavaleha'') and recipes of medicated ghee prepared by boiling with sweet drugs (vide verse 51-52). The patient should habitually indulge in taking different types of ''yapana basti'' (a type of medicated enema), ''kshara basti'' and ''anuvasana basti'' (discussed in [[Siddhi Sthana]]). He should also take different recipes of ''arishta'' prepared from grapes (''draksharishta'') for the promotion of power of digestion. ''Abhaya leha'' described in the treatment of ''kasa'' (Cha Chi. 18/57-62) may also be taken. Alternatively the patient may also take ''pippali, madhuka'' and ''bala'' along with milk depending upon the ''doshas'' aggravated and the strength of the patient [134-138]

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==== Summary ====

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=== Summary ===

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== Vidhi Vimarsha (Applied Inferences ) ==

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==== Pathological factors ====

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=== Pathological factors ===

*''Dosha'': ''Pitta'' dominant three ''dosha, sadhaka'' and ''ranjak pitta, vyana'' and ''samana vata, avalambak'' and ''kledaka kapha''

*''Dhatu'' (vitiated factors): ''Rasa, rakta, mamsa'' and ''meda''

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*Basic principles of treatment: ''Shodhana'' (mainly ''virechana'') and ''shamana'' (mainly ''pitta shaman'') as per ''dosha'' dominance

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==== General considerations ====

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=== General considerations ===

''Pandu'' can be related with the disorders of improper formation of blood tissue due to vitiation of ''pitta dosha''. ''Pitta dosha'' is considered to be responsible for all digestion, transformation and metabolism processes in the body. Therefore, the disorders like anemia, nutritional deficiency are mainly considered under ''pandu roga''. The disorders which include pathologies of impaired metabolism and formation of plasma, blood, muscles and fat can also be referred under the umbrella of ''pandu roga''. These include thyroid function disorders, hematological disorders like thalessemia, jaundice etc.

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==== Etiological factors observed in present era ====

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=== Etiological factors observed in present era ===

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===== Diet =====

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==== Diet ====

The dietary factors that cause vitiation of ''pitta dosha'' and poor nutritional status of ''rakta dhatu'' are enlisted to cause ''pandu''. These include the items having sour, salt, pungent taste, hot potency, alkaline nature, mutually contradictory and unwholesome food. These shall be avoided to prevent ''pandu''.

*Food with sour taste (''amla ahara'') includes sour curd, lemons, citric acid, pickles, and food with preservatives as jams, cold drinks, sauces, tamarind etc.

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Some scientific studies have proven the role of some of the ''aharaja'' factors in the causation of ''panduroga'' as tea (considered as ''ati ushna nidana'') has been proved to cause iron deficiency anemia by interfering with the absorption of iron. Similarly ''madya'' (alcohols) cause megaloblastic anemia by hampering the folate absorption.

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===== Lifestyle =====

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==== Lifestyle ====

Excess day time sleep, exercise beyond one’s capacity and at improper time can lead to ''pandu''. Therefore, proper quality sleep and proper exercise are preventive measures for ''pandu''.

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===== Psychological factors =====

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==== Psychological factors ====

Passion, worry, fear, anger and grief can affect digestion leading to poor nutritional status. Hence blissful state of mind is needed for proper nutrition. Rai and Kar in their observational study showed that worries, fear and grief are major etiological factors for iron deficiency anemia. These factors cause significant reduction of serum and bone marrow, while inhibiting the process of erythropoiesis. The inflammatory mediators such as IL-6, hepcidin are mediators in this pathology originated from grief and fear.<ref>Rai Shalini, Kar Anukul C. A review of role of psychological factors in the etiopathogenesis of Pandu roga with reference to iron deficiency anemia.Ayu,2016 Jan-March,31(1):18-21. </ref>

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===== Iatrogenic factors =====

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==== Iatrogenic factors ====

Improper administration of oleation therapy and [[Panchakarma]] procedures can lead to ''pandu''.

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===== Pathophysiology =====

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==== Pathophysiology ====

The cardinal feature of pandu is appearance of pallor on skin of the patient. Complexion and luster of skin is maintained by ''rasa'' and ''rakta dhatu''. The texture is maintained by ''mamsa dhatu''. Unctuousness is maintained by ''meda dhatu''. These four ''dhatus'' are important for maintaining the natural appearance of skin. In ''pandu'', the vitiated ''pitta'', due to its hot and sharply acting properties, impairs digestion process at ''rasa, rakta, mamsa'' and ''meda dhatu'' leading to their poor formation. The ''rasa'' transport channels originate in the heart and its vessels. The origin of channels of ''rakta'' is in the liver and spleen. Therefore, symptoms related to cardio-vascular system and hematological system.

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[[File:Pandu.png|500px]]

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===== Clinical features and conditions resembling the disease =====

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==== Clinical features and conditions resembling the disease ====

'''Premonitory symptoms''': Palpitations, dryness, lack of sweating, fatigue.

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The following clinical features are observed in ''pandu''. The involvement of ''dosha, dushya'' and channels are as given in the following table:

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====== Signs ======

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==== Signs ====

{| class="wikitable"

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|}

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====== Symptoms ======

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==== Symptoms ====

{| class="wikitable"

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|}

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====== Differentiating features of ''dosha'' dominance ======

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==== Differentiating features of ''dosha'' dominance ====

{| class="wikitable"

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|}

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====== Consequences of ''dhatu kshaya'' ======

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==== Consequences of ''dhatu kshaya'' ====

{| class="wikitable"

|-

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| Decrease in lipids, endocrine secretions regulating lipid metabolism

|}

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====== List of diseases with features as observed in ''pandu'' ======

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==== List of diseases with features as observed in ''pandu'' ====

{| class="wikitable"

|-

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The observations of resemblance with diseases in conventional system of medicine show that all types of anemia specially megaloblastic anemia, pernicious anemia, hypothyroidism, haemolytic anemia can be considered under umbrella of ''pandu''. The objective parameters used for these disorders can be utilized for research on efficacy of [[Ayurveda]] therapies in management of ''pandu''.

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==== ''Kamala'' ====

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=== ''Kamala'' ===

In the second part of the chapter ''pandu, kamala'' is elaborately described. If a person suffering from ''pandu'' follows ''pitta'' provoking diet and lifestyle, he suffers from ''kamala''. This shows ''kamala'' is consequence of ''pandu'' or ''pandu'' is essential causative factor for ''kamala''. This shows the relation of jaundice originated due to hemolytic anemia. In other types of jaundice, this notion is not observed in practice. ''Kamala'' can occur without ''pandu''. (Su.Utt.44/9, A.Hri.Ni.13/15-17)

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Yellowish discoloration of sclera, skin, face, nails, and urine associated with constitutional symptoms like anorexia, debility, indigestion, loss of physical strength is called ''Kamala''.

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===== Types of ''kamala'' =====

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==== Types of ''kamala'' ====

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====== 1. ''Shakhashrita Kamala/Alpa pitta'' (''Dhatu ashrita'') ======

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==== 1. ''Shakhashrita Kamala/Alpa pitta'' (''Dhatu ashrita'') ====

The passage of pitta is obstructed by vitiated ''kapha'' and not allowing ''pitta'' to enter ''kostha'', it will cause excess of ''pitta'' in body tissues in ''Shakhasrita Kamala''. This involves the obstructive pathologies at hepatic circulation. As the ''pitta'' cannot enter the gastro-intestinal tract, it leads to clay colored stools. In obstructive jaundice, bilirubin has no access to the intestine and it is the reason for pale stools.

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This description of stools being clay colored, but the urine being yellow shows that they were very close in concept to the modern day physiopathology of obstructive jaundice especially hepatocellular ones (wherein due to an inability of the bile to pass into the gastrointestinal tract it circulates into the blood and the conjugated bilirubin being water soluble fraction is filtered and passes out into the urine). Further the description of ''pitta'' being the bi-product of ''rakta'' is also very similar to the fact of bile being produced as a result of Red Blood Cell destruction. The most common cause is gall stones in the common bile duct and pancreatic cancer in the head of pancreas. Also, a group of parasites known as liver flukes can live in common bile duct causing obstructive jaundice. Biliary atresia, cholanjiocarcinoma, pancreatitis, cholestasis of pregnancy and pancreatic pseudocysts are causes for obstruction of bile flow into the duodenum.

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====== 2. ''Kostha Shakhashrita Kamala/bahu pitta'' (''Maha Srotasashrita'') ======

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==== 2. ''Kostha Shakhashrita Kamala/bahu pitta'' (''Maha Srotasashrita'') ====

''Bahupitta kamala'' or ''Kostha-shakhasrita kamala'' mostly resembles the pre-hepatic and hepatocellular jaundice. Pre-hepatic jaundice is caused by anything which causes haemolysis. Pre-hepatic cause include severe malaria, certain genetic diseases such as sickle cell anemia, spherocytosis, thalassemia, pyruvate kinase deficiency and glucose 6-phospate dehydrogenase (G6PD) deficiency, which lead to increased destruction of red cells and therefore hemolytic jaundice. Hepato-cellular Jaundice can be caused by acute or chronic hepatitis, hepatotoxicity, cirrhosis, drug induced hepatitis and alcoholic liver disease.

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==== ''Haleemaka'' ====

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=== ''Haleemaka'' ===

''Haleemaka'' is a further stage of ''pandu''. Reduced oxygen carrying capacity of blood (reduced ''jeevan karma'') causes depletion of strength and work capacity. This further leads to lack of libido and bodyache. Condition resembles cholestasis. Bile stasis and back pressure leads to liver failure which leads to the further symptoms of ''halimaka'' or sclerosing cholangitis. It is characterized by severe fatigue (''bala utsaha hani''), jaundice (''harita pita meda''), dark urine, cirrhosis, portal hypertension and hepato-megaly.

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==== ''Panaki'' ====

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=== ''Panaki'' ===

''Panaki'', another disease in same context of ''halimaka'', explains the condition of malabsorption especially of fat due to lack of bile juice in digestion due to obstruction which leads to steatorrhoea (''bhinna varcha''). Reduced fat absorption leads to deficiency of fat soluble vitamins such as A, D, E and K.

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==== ''Kumbha Kamala'' ====

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=== ''Kumbha Kamala'' ===

The description of ''kumbha kamala'' denotes the advanced stage of ''Kostha-shakhasrita kamala'' wherein the main seat of pathology is situated somewhere in the gastro-intestinal tract. ''Kumbha'' is one of the synonyms of ''koshtha''. Edema is described as one of the important clinical features of ''kumbha kamala'' (Su. Utt. 44).

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*Drowsiness (''tandra''), confusion (''moha'') are further symptoms of hepatic encephalopathy. Neuropsychological findings are experienced in all phases of hepatic encephalopathy. It is experienced as forgetfulness, mild confusion and irritability, inversed sleep pattern followed by lethargy and personality changes. The third stage is marked with worsened confusion and in fourth stage is coma. ''Mada, Murchha'' and ''sanyasa'' are mentioned earlier as disorders due to vitiated blood in [[Vidhishonitiya Adhyaya]].

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==== Management of Diseases (Treatment Protocols) ====

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=== Management of Diseases (Treatment Protocols) ===

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===== Current clinical practices in treatment of ''pandu'' and ''kamala'' ( referred from Chikitsa Pradeep) =====

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==== Current clinical practices in treatment of ''pandu'' and ''kamala'' ( referred from Chikitsa Pradeep) ====

{| class="wikitable"

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|}

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===== Evidence based clinical practices =====

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==== Evidence based clinical practices ====

*In a study carried out by Shazi L. and Thakar A., ''Amalaki rasayana'' was found effective in management of iron deficiency anemia. However the efficacy was equal in clinical parameters and less in biochemical parameters in comparison to conventional drugs a combination of folic acid and ferrous sulphate. <ref> Shaizi Layeeq, Thakar A.B. Clinical efficacy of Amalaki rasayana in the management of pandu(iron deficiency anemia). Ayu.2015.July-Sep.36(3):290-297. </ref>

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*Tewari et.al. studied the ethnopharmacological approaches to the therapy of jaundice<ref>Tewari D, Mocan A, Parvanov ED, Sah AN, Nabavi SM, Huminiecki L, Ma ZF, Lee YY, Horba´nczuk JO and Atanasov AG (2017) Ethnopharmacological Approaches for Therapy of Jaundice: Part I. Front. Pharmacol. 8:518. doi: 10.3389/fphar.2017.00518</ref> and highly used plant species from acanthaceae,euphorbiaceae, asteraceae, combretaceae and fabaceae family in the management of jaundice. The team of researchers elaborately studied hystorical perspective of jaundice, its pathophysiology and enlisted 207 herbs used in management of jaundice.<ref>Tewari D, Mocan A, Parvanov ED, Sah AN, Nabavi SM, Huminiecki L, Ma ZF, Lee YY, Horba´nczuk JO and Atanasov AG (2017) Ethnopharmacological Approaches for Therapy of Jaundice: Part II. Highly Used Plant Species from Acanthaceae, Euphorbiaceae, Asteraceae, Combretaceae, and Fabaceae Families. Front. Pharmacol. 8:519. doi: 10.3389/fphar.2017.00519</ref>

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=== Research studies on ''pandu'' ===

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== Research studies on ''pandu'' ==

Some studies are available on the internet which depict the efficacy of various Ayurvedic drugs having iron (in the form of ''lauha'' and ''mandura'') compounds in the management of ''pandu'':

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So, further studies need to be done in order to know the efficacy of these drugs and mechanisms in the various types of anemia.

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==== Principle of treatment for ''kamala'' ====

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=== Principle of treatment for ''kamala'' ===

The management of ''kamala'' by the drugs stated in the chapter has been found to show good results but the mechanism of their action is still not clear. Practically few studies are available on the net which prove the efficacy of ''Ayurvedic'' compounds in the management of hepatocellular jaundice. <ref>Nirmal kumar and Anil kumar singh. Phalatrikadi kvatha - an ayurvedic hepatoprotective drug. International journal of research in pharmacy and chemistry.2013, 3(3) Available online at www.ijrpc.com</ref>

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=== List of Research Works done ===

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== List of Research Works done ==

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==== IPGT&RA, Jamnagar ====

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=== IPGT&RA, Jamnagar ===

#Chaudhary sudhakar (1958): Pandu Roga Nidana.

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#Sarkar P K (2005): A comparative pharmaco-pharmaceutico Clinical study of lauha bhasma and mandura bhasma w.s.r. to Panduhara effects.

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==== Banaras Hindu University, Varanasi ====

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=== Banaras Hindu University, Varanasi ===

#Trivedi R D (1979):Hematological and clinical stubby in pandu.

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#Agrawal N. Assessment of Effect of Mandura Bhasma in Iron Deficiency Anemia in Children, MD thesis. P.G. Department of Kaumarbhritya. Varanasi: IMS, B.H.U; 2007.

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==== National Institute of [[Ayurveda]], Jaipur and others ====

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=== National Institute of [[Ayurveda]], Jaipur and others ===

#Tyagi R. M. (1980): Pandu Roga Evam Vajra Vatak Mandura .

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#Kumath V. (2006): A Comprehensive Study of Haritaki with Special Reference to the Efficacy of Terminalia chebula Retz. on pandu Roga, MD thesis. P. G. Department. of Dravyaguna, Government. Ujjain, Madhya Pradesh: Autonomous Dhanvantari [[Ayurveda]] College and Hospital; 2006.

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=== Potential areas /scope for further research ===

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== Potential areas /scope for further research ==

The following drugs referred in management of ''pandu'' need to be researched more for providing evidences of its efficacy in anemia and related disorders in comparison to conventional management:

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#''Dhatryarishta''

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=== References ===

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== References ==

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